AFRICA MUST ACT WITH GREATER URGENCY ON HIV/AIDS AND THE RIGHT TO HEALTH Statement by CSOs at the Fourth Ordinary African Union Summit of the Heads of States, 24-31st January 2005, Abuja, Nigeria Signed by the African Network for the Campaign on Education for All (ANCEFA), African Womens Development and Communications Network (FEMNET), African Centre for Democracy and Human Rights (ACDHR), Center for Democracy and Development (CDD), Pan African Movement (PAM), Pan African Development Education and Advocacy Programme(PADEAP), West African Students Union (WASU), Womens Rights Advancement and Protection Alternatives (WRAPA), Development Network of Indigenous Voluntary Agencies (DENIVA), Fahamu, ActionAid International, Oxfam GB Summary The fourth Ordinary African Union Summit of the Heads of States takes place at a time when the consequences of poorly financed and collapsing public health services across the continent can only be described as a public health emergency. Returning to Abuja where four years ago they committed themselves to accelerate the fight against HIV/AIDS, Tuberculosis and other related infectious diseases, it is clear that key obstacles continue to prevent hundreds of millions of Africans from realising the right to health. African Governments and the African Union must reinvigorate the fight against the violation of HIV/AIDS and health related rights. Recommendations - African Governments must commit to increasing GDP allocation for health by three per cent each year in order to reach the 2001 Abuja Summit commitments of 15%. - African government should ensure that treatment of AIDS and infectious diseases is provided free, reaches vulnerable groups and in an accountable manner. - African Governments, who have to yet ratify the AU Protocol on the Rights of Women, must do so. It is a major instrument in securing the right to health for Africa's women and girls. - The African Union Commission must lead on lobbying the G8 in 2005 for debt cancellation and measures from industrialised countries to compensate for the brain drain of African health workers. - The African Union Commission must lead on lobbying the G8 in 2005 for debt cancellation and securing measures from industrialised countries to compensate for the brain drain of African health workers. - African Governments must mandate the African Union Commission to champion for enabling laws and policies in member states and a coordinated global advocacy approach towards the WTO Hong Kong Inter-ministerial in December 2005. Situational analysis Across our continent the health status of women remains precarious and in many instances, worsening, not only because of HIV but also because of the many unacceptable inequalities that exist in women's health, the limited choices that are made available to women and finally, the lack of accountability for their health. - Pascal Mocumbi, Prime Minister, Mozambique, 2003. The majority of Africa's 800 million citizens continue to remain locked out of health facilities across the continent. By the time the Summit opens, Africa will have lost 20 million people to the plague of AIDS. Behind them, they would have left 12 million orphans to fend for themselves. While our leaders meet, outside the doors of the Abuja International Conference Centre, 80% of the 40 million people currently living with HIV/AIDs across the world will be struggling to fight a debilitating disease that in some parts of the industrialised world is no longer a killer disease. 55% of these will be women. By the time the Summit opens on the 24th January, 90 million African women and girls will have been forcibly circumcised or had their genitals mutilated. Between the opening and the closing Summit ceremonies, 77,000 women and girls will have undergone unsafe abortions in countries where restrictive abortion policies ensure that no standards can be maintained or monitored. As a result of this and other factors, a staggering 47/48 sub-Saharan African countries will not meet the goal of reducing maternal mortality and one in ten babies will not survive child birth due to poor and inadequate health infrastructure in Africa. Yet, this is sadly no longer news in a continent numbed by the domestic stories of neglect, blocked access to life-saving drugs and poverty. What could be news is the scaling up of international and African public resources into expanding access to health-care services. Expand public financing for health and education When African Heads of States met in Abuja in April 2001, they correctly declared HIV/AIDS, Tuberculosis (TB), and other related infectious diseases (ORID) as a state of emergency. Recalling and reaffirming their commitment to all relevant decisions, declarations and resolutions in the area of health and development and on HIV/AIDS, particularly the "Lome Declaration on HIV/AIDS in Africa" (July 2000) and the "Decision on the adoption of the International Partnership against HIV/AIDS" (Algiers 1999) they stated; "WE COMMIT OURSELVES to take all necessary measures to ensure that the needed resources are made available from all sources and that they are efficiently and effectively utilized. In addition, WE PLEDGE to set a target of allocating at least 15% of our annual budget to the improvement of the health sector." Now known as the "Abuja 15% commitment" this target was seen as a critical contribution to the fight against HIVAIDS and other diseases. Shockingly, despite this public commitment, four years on many countries continue to spend less than 10% of the revenue on health. African Governments must commit in this Summit to increasing GDP allocation for health by three per cent each year in order to reach the 2001 Abuja Summit commitments of 15%. New research published by the Global Campaign for Education and endorsed by UNAIDS, shows that a complete primary education makes a strong and direct impact on HIV infection rates, especially among young women. Girls with a complete primary education are 2.2 times less likely to contract HIV than those with some or no primary education. Education equips young people to understand and apply facts and gives them the status, clout and confidence to avoid unsafe and exploitative relationships. Investing in free primary education for everyone but especially for girls, is one of the most effective and urgently needed measures to fight the epidemic. Investing in secondary education would bring additional benefits. Consequently, the AU needs to give priority to free, universal and compulsory basic education with gender equity, both in its own strategies for development and poverty reduction, as well as in its dialogue with forums such as the G8. Debt cancellation is pre-requisite for progress The heavy external debt burden ...continues to mortgage African economies and cast a shadow over our People's' future. To date, the proposed remedies are ad hoc. - Secretary General of the Organisation of African Unity, July 2002 A comprehensive AIDS plan for Africa would cost US$10 billion per year, yet African nations spend one and a half times this amount in debt servicing. In many countries, more is spent on debt servicing than on education and health or is received in aid grants and foreign direct investment. For the same money, the global fund against HIV/AIDS, Malaria and Tuberculosis could stop these diseases and provide Anti-Retrovirals (ARVs) for the three million people living with HIV in all developing countries not just Africa. This absurdity can only be seen from the experience of one country. Tanzania for instance, currently pays US$39 million dollars per annum in debt servicing while receiving only US$27 million in aid. It is revealing to recall that after the second world war, Germany was considered to be harshly penalised for having reparations set at 7% of its exports, yet in 2005 Tanzania is supposed to "adjust" and grow with debt servicing set at 60% of its exports. Yet, this Summit occurs at a time when momentum has built once more around the necessity for debt cancellation. Several G8 countries have bi-laterally cancelled debts owed by African countries. In February 2005, the G7 Finance Ministers will consider proposals to underwrite debt cancellation by committing additional bi-lateral financing or by re-valuing IMF gold reserves. The benefits of this would be immense. Debt cancellation would enable countries like Ethiopia to expand access by doubling its expenditure on health and thus reaching beyond the 60% who are currently reached by health services. There is precedence in Africa for successful re-channeling of debt relief into basic social services. At least six countries in Africa offer insight into the possibilities debt cancellation could create. In Benin for example, 54% of HIPIC relief monies was channeled into improving health programmes by recruiting health staff for rural clinics, implementing HIV/AIDS and anti-malarial programmes and improving access to safe water and increasing immunisation. Malawi has been able to allocate a 30% cut in debt servicing per year to enhance their HIV/AIDs health care system. US$1.3 million of debt relief money has been critical to resourcing Uganda's National HIV/AIDS plan. Cameroon was able to launch a comprehensive national HIV/AIDS strategic plan funded to the tune of US$114 million with help from debt savings. In Niger, a special programme that focuses on rural education, health, food security and water systems has been fully financed through HIPC. This has mainly been used so far in building classrooms and rural clinics. In Burkina Faso, HIPC relief has been spent on health (33%), education (39%) and rural roads (28%). As Jubilee Zambia coordinator Teza Nchinga notes, "Respect for the basic human rights (food, health care and education) of millions of Zambians should take priority over repayment of debts to comparatively wealthy creditors especially when capital on these debts has already been paid a number of times over." The African Union Commission must lead on behalf of African countries by aggressively demanding debt cancellation from the G8 in 2005. African Governments on the other hand, must follow the example of these six countries who have had re-channeled monies freed up from debt relief into strengthening health systems including the retention of health workers. Industrialised countries must deliver on their aid commitments Currently, despite the increases pledged in the UN Financing For Development Conference in Monterrey, rich countries spend half of the foreign assistance they did in 1960. If they were to meet the OECD targets of 0.7% of their GNP this would increase aid levels from US$70 billion to US$190 billion dollars. Yet, only the UK and Spain have set dates to meet these targets. 12 other countries are far from this and do not seem to be in a hurry. Compared to expenditure on defense or domestic agricultural subsidies, this would be a very small amount. Looked at in terms of the cost to individual taxpayers, it would cost an additional US$80 dollars per person per year or put more simply, the average price of one cup of coffee a week. G8 countries continue to prioritise aid to countries where they have geo-political interests rather than fighting poverty. Over 2004, America set aside US$ 65 billion dollars for fighting the war in Afghanistan and Iraq. This could have financed the exact annual budget deficit for the entire continent of Africa. Put another way, six months of US funding for the war in Iraq (US$ four billion) could have met the annual budget deficit for the global fund against HIV/AIDS, Malaria and Tuberculosis. Yet increasing aid is only one measure, improving its quality is another. For instance, nearly 30% of aid is tied to goods and services from donor countries. In the case of the US, this figure is as high as 70%. The quality of foreign assistance also continues to be undermined by IMF and World Bank fiscal and macro-economic models, which act to constrain expenditure on basic social services. In a study of twenty Poverty Reduction Strategies, sixteen were found to contain fiscal targets for inflation and the budgetary envelope that had not been subjected to public discussion. They were targets that had been established by the World Bank or the IMF. Last year for instance, Ethiopian and Tanzanian Governments will have to meet 85 and 78 policy conditions respectively. The AU clearly sees itself providing leadership, monitoring states performance and accountability, advocacy with states and beyond, setting up standards, harnessing new continental initiatives, and as a knowledge hub. This clear emphasis on harmonising the plethora of new initiatives and monies that are offered for flooding Africa and which are, in many cases, confusing national plans and programmes, is welcome. To this end, the AU must challenge the proliferation of uncoordinated initiatives such as the US PEPFAR Presidential Initiative. Bilateral initiatives such as PEPFAR may reinforce donor-driven approaches, increase the administrative burdens of recipient countries and drain resources away from existing, experienced, multilateral initiatives. Such initiatives create parallel systems where the national government using inexpensive generic fixed dose combinations and that of PEPFAR using expensive brand names. This leads to confusion of both patients and health providers. The African Union must take a more vigorous lead in engaging the international community to deliver the Monterrey promises and improve the volume and quality of foreign assistance to Africa. It is vital that donors' initiatives and programmes should implement nationally defined policies especially regarding access to medicines. Improving Access to Care and Support The major challenge facing the people living with AIDS and people affected by AIDS is the issue of access to treatment and care. The World Health Organization (WHO) in December 2003 came up with an initiative to treat three million people by 2005. This is believed to be approximately half of the estimated six million people in dire need of antiretroviral therapy. This is the popular 3 by 5. Despite the fact that some African governments have subsidized distribution programmes, less than 1% of Africans in need of ARV treatment had access to ARVs, compared to 85% in developed countries in 2004. South Africa has committed to providing free treatment to 53,000 people by March 2004. This is a fraction of South Africa's HIV positive population, estimated to be over five million. The Nigerian government began a treatment programme to provide ARVs for 10,000 people in November 2002. At a conservatively estimated number of 3 million people living with HIV&AIDS in Nigeria in 2004, this is quite clearly inadequate. Access to ARVs is also determined by power within and between households. Findings from CSO participatory research studies in Zambia and Nigeria suggest that intra-household power relations conspire to constrain women's access to ARVs. Women in Zambia have a disproportionate access to ARVs (30%) despite comprising of 50% of the population. In January 2004, less than 30% of people who had access to ARVs were women in Zambia. In many families who cannot afford to have more than one person on ARV, it is the male head of household that is chosen. At another level, scanty or total ignorance of prevalent diseases, the weak bargaining position of women and the pervasive cultural endorsement of male liberty to have free and multiple sexual relationships (in and out of marriage) has escalated the distributive impact of STDs and led to the high prevalence of HIV/AIDS across communities all over Africa. In many countries across Africa the right to health is not enshrined in either the constitution or laws. It is in this context that the African Union Protocol on Women's Rights and in particular the provisions in articles 14 and 15 significantly contribute to grounding the obligations of Governments. Yet, despite encouragement by the African Union Commission under the leadership of President Konare and civil society campaigning, only seven Governments have ratified the Protocol, a further 33 have signed but not ratified. To this end, African Governments who have not yet done so must re-commit to ratify with urgency, the AU Protocol on the Rights of Women, as a major instrument in securing the right to health for Africa's women and girls. Class equities also affect the distribution of ARVs. Interviewed recently, a 29 year old father of three kids in Nigeria said; "The ARV that come to the center are not given to those of us who have come out to declare our status, but to those BIG men who bribe their way through and we are left to suffer and scout round for the drug. " Attempts to bring down the costs of ARVs are obviously the way forward. In Nigeria, Malawi and Zimbabwe, tariffs on essential drugs have been removed. The Governments of Zambia and Mozambique have issued compulsory licensing for ARVs for their treatment programmes. Zimbabwe has also allocated precious foreign currency to a local company to manufacture generic ARVs, and is currently running trials on AZT at two of its largest hospitals. However, Zimbabwe's lack of foreign currency has made it difficult to secure an adequate supply of drugs. In Kenya and Malawi also many public hospitals have no drugs for treatment of HIV/AIDS-related infections. Access to essential medicines rests on African countries being able to domestically produce or source cheap drugs from southern based generic drugs industries. The AU should consider initiating dialogue with WHO, UNCTAD and the EC to explore the feasibility of establishing African centers of excellence in the producing of high quality local production of medicine especially ARVs. African states should be encouraged to influence both public and private health service providers to dispel misinformation about generic drugs being inferior to brand products, eliminate the costs of ARVs to users and actively target the rural poor with special emphasis on gender equity. Key to this will be the replication of policies that cut taxes and tariffs and promote price regulation to countries that have not already done so. We welcome existing plans for a continental conference on the rights of people with HIV/AIDS to raise the profile of rights abuses and to chart a new chapter in the evolution of national laws and standards consistent with the spirit of the African Charter of Human and Peoples Rights. We call on the AU Commission to extend an invitation to People with AIDS organizations and networks across the continent to help design this process. African Governments must mandate the African Union Commission to champion for enabling laws and policies in member states and a coordinated global advocacy approach towards the WTO Hong Kong Inter-ministerial in December 2005. The AU must ensure that new trade agreements especially Trade Related Aspects on Intellectual Property Rights (TRIPS), bilateral and regional trade agreements do not undermine access to medicines in Africa. The absence of effective conditions to fight HIV/AIDS and other infectious diseases such as malaria, tuberculosis and polio conditions and poor remuneration of African health workers has led to an exodus of trained health personnel. Calculating the cost of training, every doctor that leaves the continent costs Africa US$60,000. This results in a staggering subsidy to G8 countries of US$500 million every year just for health personnel. To increase access to medicines African governments should redirect aid and debt money towards investing in basic health services including retention of health workers. Donors' initiatives should follow national medicines policies especially using inexpensive generic fixed dose combinations. The AU should advocate with states, donors and the pharmaceutical industry to decrease the prices of second line treatment for HIV. Conclusions As African Governments meet once again in Abuja, they must embrace the opportunity of an invigorated African Union Commission to turn words into further deeds and directly confront the state of emergency. The temptation to simply re-affirm the 2001 Abuja Declaration must be avoided in order for the costs of this Summit to be justified. Increasing domestic resourcing, improving the quality of health programmes particularly to rural communities and delivery on debt cancellation are key to preventing hundreds of millions of Africans from being denied the right to health. Recommendations - African Governments must commit to increasing GDP allocation for health by three per cent each year in order to reach the 2001 Abuja Summit commitments of 15%. - African government should ensure that treatment of AIDS and infectious diseases is provided free, reaches vulnerable groups and in an accountable manner. - African Governments, who have yet to ratify the AU Protocol on the Rights of Women, must do so. It is a major instrument in securing the right to health for Africa's women and girls. - The African Union Commission must lead on lobbying the G8 in 2005 for debt cancellation and measures from industrialised countries to compensate for the brain drain of African health workers and stop recruiting more workers. - African Governments must prioritise monies saved by debt relief for strengthening health systems that ensure the retention of health workers. - African Governments must mandate the African Union Commission to champion for enabling laws and policies in member states and a coordinated global advocacy approach towards the WTO Hong Kong Inter-ministerial in December 2005. * Useful Reading Materials - African Union, Report of the African Summit on HIV/AIDS, Tuberculosis, and other related infectious diseases. Abuja Nigeria, April 2004 - African Union, HIV/AIDS Strategy 2005-2007 - ActionAid International, Responding to HIV/AIDS in Africa, a comparative analysis of responses to the Abuja Declaration in Kenya, Malawi, Nigeria & Zimbabwe, June 2004 - ActionAid International, 3 by 5: Ensuring HIV/AIDS Care for All. June 2004 - Fahamu/SOAWR, Pambazuka News 190: Special Issue on the Protocol on the Rights of Women in Africa: A pre-condition for health & food security, January 2005 - Oxfam International, Paying the Price, January 2005